Hysterectomy is the second most common surgery in women in many parts of the world. 70% of hysterectomies are still performed by the abdominal route. The route of surgery chosen is often guided by anatomic considerations, type of pathological condition, patient preference, physician experience and training. Ever since Reich performed the first laparoscopic hysterectomy in 1989, this route soon began to gain popularity.

There are various classifications for laparoscopic hysterectomy. Laparoscopic techniques can be used to completely remove the uterus or facilitate a vaginal procedure. Complete laparoscopic removal of the uterus from all its supports is called total laparoscopic hysterectomy.

THE TECHNIQUES

The procedure is done under general anaesthesia with the patient in low lithotomy position. Prophylactic antibiotic is administered 30 minutes before the procedure. The bladder is catheterized. The laparoscope is introduced through the 10 mm port in the infraumbilical region. Two or four ancillary 5 mm ports are created. These can be situated in the right and left lower quadrants, suprapubic or another vertically above the lower quadrant ports just below the umbilicus. At the outset, the peritoneal cavity is first inspected to determine the pathology and feasibility of the laparoscopic approach. Any adhesions are lysed to allow adequate visualization and access to the field. Reich advocates a six step approach towards performing a laparoscopic hysterectomy:

The ureters should be clearly identified at the pelvic brim and may or may not be formally dissected so that their location is determined and all operative procedures stay clear of them.

The round ligaments are divided with unipolar coagulation and scissors. The vesicouterine fold of peritoneum is incised. The bladder can then be dissected free from the uterus and pushed down.

The infundibulopelvic ligament is dessicated with bipolar cautery most commonly and incised. The ovaries and pulled inward and cauterization is done close to the ovary to avoid damage to the ureter. If the ovaries need to be conserved, the broad ligament is cauterized and cut. Various energy sources like the bipolar, harmonic scalpel, or the Ligasure can be used for the pedicles.

With the bladder pushed down the uterine artery is skeletonised. This can be either coagulated with bipolar cautery, stapels or the ligasure or can be ligated by endosutiring.There are various uterine manipulators available in the market. The basic principles of which are to elevate the uterus, manipulate it by causing anteversion or retroversion, facilitate culdotomy by making the fornices prominent with a non-conducting inert cup from below and maintaining pneumoperitoneum after culdotomy. After securing the uterine vessels, the cardinal and uterosacral ligaments are divided. This is followed by cirumferential culdotomy with division of cervicovaginal attachments. After all the attachments of the uterus are severed, the uterus is pulled down into the vagina and it can be placed there as a plug to prevent loss of pneumoperitoneum.

The vaginal vault is closed with three sutures: one attaching the uterosacrals with the vaginal vault and another in the midline.

After the vaginal vault is closed, the abdomen is reinflated and the whole pelvis inspected to ensure haemostasis. The bleeding points are carefully examined underwater before releasing the pneumoperitoneum.

To conclude Total laparoscopic hysterectomy is a one step true laparoscopic approach. Uterosacrals not cut and there is good vault support, no shortening of vagina, it is a true infrafascial approach and there is negligible chance of vault granulation. The laparoscopic route incorporates the advantages of both routes of hysterectomy namely abdominal and vaginal. It allows surgeons with limited experience in vaginal surgery to remove the uterus without an abdominal incision in the presence of adhesions, endometriosis or adnexal disease. It also offers a brilliant magnified two dimensional view much superior to the view at laparotomy. Other advantages include accurate haemostasis, lesser haematoma and blood transfusion, less post-op infection and reduced recovery time